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Endosteal implants are part of the reconstructive armamentarium used by head and neck surgical teams in cases of trauma or tumor ablation when inadequate residual anatomy prevents the fabrication of a traditional prosthesis. Three cases of implant supported prosthesis have been presented. Use of endosteal implants is an additional step toward functional reconstruction.
Fifteen temporomandibular joint patients were evaluated preoperatively and postoperatively to evaluate the effectiveness of a composite (fascia, muscle and periosteum) temporalis pedicle flap as an interpositional disc replacement. A modified Craniomandibular Index (CMI) and Symptom Severity Index (SSI) were used to assess clinical and subjective symptoms. Eighteen months postoperatively there was a significant reduction in the CM and SS indices (P less than .001), with significant clinical improvement of the mandibular range of motion (P less than .05). However, a significant reduction of translation (P less than .01) was evident indicating that the increased mandibular opening was owing to a compensatory rotational movement. This study indicates that the composite temporalis pedicle flap is a good autogenous tissue for the reconstruction of the temporomandibular joint.
A basic prerequisite for establishing true and lasting tissue integration of a nonbiologic prosthesis is the minimal risk of adverse local or general tissue reactions. It consists of a detailed understanding of the response behavior of highly differentiated hard and soft tissues to the surgical preparation of a recipient site and the installation of the prosthesis, as well as long-term tissue adaptation and the functional demands on the anchorage unit. The complex arrangement of titanium implant material, surface physics, and biocompatibility with the host tissues will be reviewed in this article.
A 3-year-old white girl was seen because of an enlarging mass in the left side of the mandible. The mass was 10 cm in diameter and the entire left hemimandible was involved. Examination of tissue after incisional biopsy showed desmoplastic fibroma. Surgical removal of the tumor required a hemimandibulectomy. The mandible was replaced immediately with a stainless steel mesh prosthesis with an acrylic condyle. A year later, there was no evidence of recurrence. Though the mesh became exposed in one area, we believe that esthetics and function were best served by its use.
Osseointegrated implants can provide anchorage and promote prosthesis stability in a variety of oral defect situations. The application of proven TIP fixture principles and techniques to these patients has allowed high level of function to be attained with great promise for longevity.
Prosthetic aids in resections of the middle piece of the mandible. The authors describe a prosthesis which is inserted during the resection of the middle piece of the mandible. Due to its construction it prevents the soft tissues of the floor of the mouth from sinking back. Such a prosthesis has been used in 18 cases. Respiratory complications did not occur; no tracheotomy was necessary. During the postoperative phase, the prosthesis came up to expectations, but it could not prevent cicatricial contraction in the operating area. Occlusion-conformable positioning of the fragments will be achieved only it the remaining teeth are suited for function-stable prosthetic care. Consequently, secondary osteoplasty should not be abandoned.
The advances in osseointegration have resulted in an increased utilization of implants for restoration of the edentulous jaw. The success of osseointegrated implants supporting full arch prostheses has become more predictable. All implant restorations require a thorough diagnosis and a definitive treatment plan. Following a diagnostic wax-up, an optimal surgical implant template must be fabricated; it serves as a guide or prescription for placement of implants in an optimal anatomic location. The slightest misangulation of an implant may create restorative limitations. In such circumstances, alteration of the restorative design or selection of alternate materials may be required. The learning objective of this article is to review the fabrication of a combined ceramometal and resin-metal fixed/removable implant-supported mandibular hybrid prosthesis. Diagnosis, surgical template fabrication, vertical dimensions, buccal/lingual space limitations, and aesthetics are discussed.
Two cases with complete loss of the tooth-bearing portion of the mandible were repaired with a prosthesis. This type of defect can involve the loss of a large number of teeth and aggression to the remaining teeth must be limited as much as possible. A two-part "articulated" prosthesis with two rings appears to be the best adapted system. This method takes into account the requirements of for additional conventional prostheses and thus makes it possible to save the remaining teeth.
Treatment of the edentulous obturator patient requires the same basic fundamentals as used in the treatment of the complete-denture patient. Problems and considerations unique to the development, delivery, and follow-up of the complete maxillary obturator prosthesis and mandibular denture in the patient with an acquired maxillary defect are discussed. Combining laboratory and clinical research in maxillofacial prosthodontics and plastic and reconstructive surgery continues to improve the rehabilitation of these patients.
The present paper examines the development of dental and surgical methods for the reconstruction of bone defects in the lower jaw. Starting with the resection-prosthesis we highlight important stages of bone transplantation in the lower jaw. Until 1914, actually no concept existed for reconstruction of continuity in the lower jaw. Only when dentists and surgeons started working together in the First World War, a bone-transplantation concept for the lower jaw could be elaborated.
An alternative method to temporary lower jaw reconstruction with a reconstruction plate prosthesis is described. To prevent penetration of an alloplastic condyle transplant through the skull base, and to restore joint function, we have reimplanted the resected condyle after its fixation to the reconstruction plate. Postoperatively, there have been no complications. Joint function has been almost completely restored. The reimplanted condyle has been investigated after 28 months. It has undergone remarkable changes.
In search of a better, more natural appearing mentoplasty prosthesis, a new material, Silastic X7-2524 carvable soft elastomer, has been combined with a new design in a chin implant. In 50 patients over the last 2 years, a submental, subperiosteal approach with protection of the mental nerves during dissection under direct vision was utilized. Results have been excellent and complications to date insignificant. Over the 2-year follow-up period, there has been no clinical evidence of distortion or bone resorption.
During the past five years (August 1981 to March 1986), we applied 44 pectoralis major myocutaneous flaps (PM-MC flaps) for the purpose of intraoral and extraoral reconstruction following surgery in 43 cases of oral cancer. Out of a total 44 flaps, 30 flaps resulted in complete survival and 13 flaps resulted in partial necrosis, while complete necrosis occurred in only one flap. In addition, we used the iliac bone graft with the PM-MC flaps on five patients in order to reconstruct the mandible, but two cases failed. We also used replantation of the lower margin of the mandible on five patients, and all were satisfactory. In 26 living patients, all but one had no dysphasia. About more than a half of them had moderate or severe dysfunction of chewing. We were able to make prosthesis for five out of 26 living patients as recorded till today. We have to think about how to fashion functionable dentures on severe cases postoperatively. The results of our experiences show that the PM-MC flaps provide a simple, reliable and versatile method of primary reconstruction on patients with oral cancer.
Our experience using a new technique for reconstructing contour defects of facial bones has been presented. It employs particulate, cancellous bone and an implantable prosthesis accurately fabricated of polyether urethane and polyethylene terephthalate cloth mesh which can be produced in a variety of configurations. A mannequin made of these materials displaying the various parts of the craniofacial complex that have been restored or are currently under investigation is shown in Figure 10. Large cranial vault defects, orbital floors, mandibles including chin augmentation, and nasal bone deformities have been successfully restored in man. Restoration of the pinna of the ear is currently being evaluated in laboratory animals.
We describe the utilization of distraction osteogenesis in the free fibular microvascular bone graft to the mandible for increasing bone height for future osseointegrated dental implants. Successful reconstruction of a resected mandible requires restoration of both function and esthetic form. Although current reconstructive techniques restore anterior-posterior and lateral projection, often the graft's vertical height is not sufficient for the placement of osseointegrated dental implants and subsequent oral prosthesis. The patient was a sixteen-year-old male who was found to have a large desmoplastic fibroma of the left mandible, which was resected. The defect was successfully restored with a free fibular microvascular bone graft and reconstruction plate. Nevertheless, the patient had persistent problems with mastication and it was decided to perform a segmental osteotomy of the neomandible. Two internal vertical distraction devices were then placed in the mandible. The appliances were then activated five days postoperative, twice a day, for a total of 14 days. At that time 1.5 cm of distraction had occurred and the patient was placed in a consolidation phase for four months. The patient then had sufficient bone height and was restored with 8 osseointegrated dental implants.
BACKGROUND: Mandibular plates may become exposed following radiation therapy, infection, and mucosal necrosis. This may lead to early removal of the mandibular plates with subsequent instability of bone fragments. OBJECTIVE: To compare fibrin glue, a bioadhesive, with traditional sutures in closing mucosa over exposed mandibular plates in a cat. DESIGN: Prospective matched-pairs analysis. SUBJECTS: Nine cats were used, and each cat served as its own control. INTERVENTION: Bilateral mandibular plates were fixed on the buccal side of the mandible of 9 cats. The surgical defects over the plates were left uncovered. After 4 days, the plates on the right side were covered with a mucosal graft fastened with fibrin glue, and on the left side the grafts were secured with sutures. After 10 days, the grafts were excised and a histological examination was performed. RESULTS: The mean operative time for coverage was 2 minutes 11 seconds for the fibrin glue and 12 minutes 48 seconds for the sutures (P < .001). Gross examination revealed granulation or ulceration in 3 of the fibrin and 9 of the suture specimens (P < .005). All specimens displayed mild-to-moderate acute and chronic inflammation. All sutured specimens showed focal foreign body-type giant cells surrounding fragments of bone and suture. Two mandibular plates were partially exposed on the fibrin glue side. CONCLUSIONS: The use of fibrin glue to cover exposed mandibular plates is safe and well tolerated in cats. Glue application requires a shorter operative time and is associated with fewer occurrences of granulation and ulceration when compared with suture fixation. Further studies are indicated to titrate the concentration of fibrin glue and to prevent plate exposure.
OBJECTIVE: To study the relationship between soft tissue volume loss and bone resection length following lateral segmental mandibulectomy with plate reconstruction and complication rates. DESIGN: Retrospective case review of 31 patients (1989-1996), with average follow-up of 37.2 months, who were treated by lateral composite resection for oral cavity and/or oropharyngeal malignancy with primary reconstruction by defect-bridging plates. SETTING: Academic tertiary care referral center. INTERVENTIONS: Thirty patients had stainless steel and 1 patient a vitallium reconstruction plate to restore mandibular continuity. Soft tissue defects were repaired with pectoralis myocutaneous flaps (n = 25), skin grafts (n = 4), a radial forearm free flap (n = 1), or primary closure (n = 1). All patients received preoperative (n = 6) or postoperative (n = 25) radiation therapy. MAIN OUTCOME MEASURES: Overall and hardware-related complications. RESULTS: All 31 initial soft tissue repairs were successful. Subsequent complications occurred in 14 patients (45%), which included plate exposure (29%), loosened screws requiring hardware removal (29%), fistula (14%), local wound infection (14%), osteomyelitis (7%), and plate fracture (7%). Average time to complication was 7.7 months. Complication rates were 81% for bone defects greater than 5.0 cm, and 7% for those less than 5.0 cm. Bivariate analysis indicated bone resection lengths greater than 5.0 cm to be a significant predictor of both hardware-related (P = .02) and overall complications (P = .005), whereas soft tissue volume resections greater than 240 cm3 were found only to be marginally significant (P = .04) for overall complications. CONCLUSION: Extirpative losses involving more than 5 cm of bone, or tissue volume greater than 240 cm3, are associated with unacceptably high complication rates when reconstructed with solid screw stainless steel plates and this warrants consideration of alternative techniques for long-term stability.
BACKGROUND: Lateral oromandibular reconstruction using a soft tissue free flap with a first-generation locking mandibular reconstruction plate (MRP) was rejected in a previous series by the senior author (K.E.B.) owing to a high incidence of delayed plate extrusion through the cheek skin. OBJECTIVE: To reexamine this method of reconstruction using a second-generation, low-profile MRP. PATIENTS AND DESIGN: A prospective case series of 27 patients with segmental defects of the lateral mandible after treatment of head and neck cancer. SETTING: An academic tertiary care referral center. INTERVENTION: All patients had mandibular continuity restored using the Leibinger Locking System (Stryker Leibinger Inc, Kalamazoo, Mich) MRP. Associated soft tissue defects were repaired using radial forearm (n = 22) or rectus abdominis (n= 5) free flaps. MAIN OUTCOME MEASURE: Incidence of hardware-related complications. RESULTS: All microvascular flap transfers were successful. One patient experienced a plate fracture 9 months after reconstruction. Only 1 patient experienced external plate exposure, 6 months after undergoing reconstruction of a through-and-through defect. Reconstruction was successful in 25 (93%) of the cases after a median follow-up period of 19.5 months. CONCLUSIONS: The high incidence of external plate exposure in patients undergoing lateral oromandibular reconstruction using soft tissue free flaps and first-generation locking MRPs may have resulted from a plate geometry that was prone to result in extrusion. After a similar length of follow-up, the incidence of reconstructive failure was reduced by using a low-profile, rounded-contour MRP. Final assessment of the durability of this technique will require long-term follow-up.